Provider Demographics
NPI:1285641340
Name:FARRA, JODY DEAN (MA LPE LPC)
Entity Type:Individual
Prefix:MR
First Name:JODY
Middle Name:DEAN
Last Name:FARRA
Suffix:
Gender:M
Credentials:MA LPE LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1242 HIGHRIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664
Mailing Address - Country:US
Mailing Address - Phone:423-323-9289
Mailing Address - Fax:423-968-2225
Practice Address - Street 1:6 SIXTH ST
Practice Address - Street 2:CENTRAL BUILDING SUITE 205
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620
Practice Address - Country:US
Practice Address - Phone:423-968-2225
Practice Address - Fax:423-968-2225
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPE000531101YM0800X
TNLPC000282101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TPIN 13037341OtherFED GOVT TRADE PARTNER ID